At ASI Wise, to avoid confusion, we use the term sensory integration and processing difficulties. Different terms are used in different places to describe sensory integration difficulties. Some therapists may use sensory processing difficulties instead. Some may even use sensory processing disorder.
We currently have a robust test, the SIPT, that allows us to describe sensory integration difficulties and reference research evidence to interpret the unique scores and pattern of scores that the child gets across 17 test items. We can use this data to inform our clinical reasoning, create a hypothesis about what sensory difficulties are contributing to participation challenges in everyday life. We set goals, plan and deliver the intervention, Ayres’ Sensory Integration Therapy measuring therapy outcomes. This is best practice.
“Active, individually tailored, sensory motor activities contextualised in play at the just right challenge, that targets adaptive responses for participation in activities and tasks.”
ESIC Schaaf 2019
Ayres’ Sensory Integration assessment and therapy is typically post-graduate education for Occupational Therapists, Physiotherapists and Speech and Language Therapists. Please check that your therapist has ASI Education that meets level 2 education standards as recommended by ICEASI.
Sensory integration…the ability to organize sensory information for use…perception and synthesis of sensory data that enables man to interact effectively with the environment.’
Jean. A. Ayres (1972)
Ayres’ Sensory Integration combines theories and concepts from human development, current neuroscience, psychology with occupational science into a holistic framework through which we can consider a person’s development, learning and behavior.
Integrating sensory input is essential for development, it underpins learning and ensures we can participate in daily life, helping us to ;
make sense of and join together cues in the environment
‘do the right thing at the right time and in the ‘just right’ way’ – moving and using our bodies to get things done
be aware of what goes on within our own bodies;
know who we are – where we stop and start and where others begin
manage emotions and self -regulate
interact with others and the world around us – and safely
Here is a great resource to share with therapists, teachers, and families new to Ayres’ Sensory Integration to help explain Ayres’ SI in more detail.
Thank you to Ms Grieco and Ms Wooldridge for sharing this on YouTube
Just like a parent can decide a child has a cold and needs Calpol, a sensory rich home environment can help support development. However just like a child may need a Dr, Dentist or other specialist if they have a more serious illness, what some people need is specialist intervention.
Sensory Integration therapy requires years of training, first just to become a therapist and then the advanced training needed to accurately assess, develop a personalised intervention plan and then carry out the intervention. We might all know when tonsils need removing, but few of us would do it at home. Telling someone about how tonsils get removed or how sensory integration happens is very different to actually doing it, and doing it safely and so that the outcome is as expected. Sensory integration therapy is not just about swinging on a swing or bouncing on a ball – it is about so much more. And is definitely not about just about wearing headphones and having a bouncy cushion.
The superb article from AOTA’s CHOOSING WISELY programme – see link below – got me thinking. I get weekly emails from people offering to treat other people’s children without training, offering Sensory Profile assessments by mail from a questionnaire when they are not even a therapist.
Share this blog and have interesting discussions with clients, colleagues and line managers. As relevant here in UK and Ireland as in US. This really confirms what we teach in our modules and promote as an organisation; including the best standardised norm referenced tool currently at our disposal – the SIPT. No or limited assessment waters down efficacy. Standardised assessment (when possible) structured clinical observations and thorough clinical reasoning using a clear process are imperative. Data driven decision making.
ASI WISE was recently invited to deliver a presentation about Autism and sensory issues to a UK National Autistic Society meeting. Our presentations to the audience addressed the science and evidence behind autism and explored a families experience of sensory integration therapy.
Since the presentation we have had interesting conversations with some parents who attended. A common theme has been parents discovering that motor and praxis difficulties are part of sensory integration theory and therapy, and that ‘sensory’ in autism isn’t just about sensitivity.
Here is a great blog by an adult with autism who describes those sensory integration difficulties from visual scanning to actually doing.
It’s the summer holidays for most schools in England, including my kid’s schools. I’m well known for my love of messy/ tactile play, and summer holidays and messy play are made to go together.
First of all, can I just say that messy play is not just about the sensory input, it’s not a “sensory session”, it’s certainly not a substitute for “sensory integration therapy”?
All play is sensory.
All activity is sensory.
Messy play is a about normal development and learning through a playful activity using tactile experiences and experimentation. It should be fun, it can be intensely therapeutic, and it can form a part of sensory integration therapy session, but overuse of the word “sensory” for activities like this weakens the power of true sensory integration therapy.
Second of all, can I just say that messy play is not a substitute for natural tactile experiences? Messy play is not a substitute for muddy walks, tree climbing, animal handling and other important life and learning experiences. It can scaffold and enable those activities for children who find these experiences difficult to tolerate, but there’s nothing like nature and the great outdoors for kids’ sensory skills.
Here are some of the reasons I love messy play…
It teaches basic cookery skills, but nobody has to actually eat the product
Through making recipes, you can practice opening packages, pouring, measuring, stirring (and holding the bowl still at the same time) and following a recipe. But you don’t have to worry about food hygiene, if the child drops it on the floor, picks their nose, spits, or anything els. You don’t have to pretend it’s delicious. But there is still a tangible result.
It teaches flexibility of thinking and problem solving
So many times I say to kids “OK, that doesn’t look like it does on my picture, what did we do wrong?”, followed by “OK, let’s try that then!”. It’s amazing to watch our children move from “it’s gone wrong, bin it” to experimenting to try and improve the outcome. When I hear “it’s too runny, add more flour” I smile, I count this as a breakthrough parenting moment.
It can be really helpful to use non-specific language, I love seeing that look and a laugh when I say ‘you need a good amount of this’ or ‘give it a squirt of that’. I say we’re working on estimating.
It teaches art, creativity and scientific experimentation
We’ve made beach scenes out of shaving foam and cornflour gloop, farms from rice and silly string and just beautiful visual effects from any range of strange concoctions. I love that moment of “what happens if I mix this with that?”. So long as you’ve checked what you’re using properly, to make sure it’s safe, the worst that will happen is a sticky mess.
Beware of borax as a substitute in cheap homemade slime recipes!
It teaches communication
It can be a great motivator that isn’t food-based; practising choice-making, turn-taking and asking for help is really easy with a tin of shaving foam and some dry pasta. You can follow a recipe, practising reading and maths. Make visual recipes pictures of the scoops of flour and oil, with laminated recipes so the child can tick off each step they do – wiping clean at the end. Get older kids to research their own recipes on the internet and print them off ready for the session.
It teaches motor skills and tactile discrimination
Opening packets, pouring to a measure and sprinkling need I go on? And then squeezing, pressing, rolling, stretching and cutting. It’s amazing for fine motor skill development. You can hide things in a messy play tray or a ball of playdough for the child to find and choose the perfect texture.
It exposes the child or young person to new sensations
You will make lots of smells with microwaveable soap kits, you will spill liquids, you will touch textures and the outcome is often unpredictable.
It can help with food aversions
Food-based textures and odours can become familiar through messy play. Exploration of food and food-like substances in a calm, fun activity without the pressure and anxiety of being pushed to eat can help to break down anxiety responses to foods, meals and eating.
Or at least, you should make sure it is.
So, with all of that in mind, Over the next few days, I’ll give you 6 of my favourite recipes, one for each week of the English summer holidays. There are loads of recipes out there, I have a whole book of slime recipes (yes, really) but these ones are tried and tested and hopefully varied.
We should use and value our specialist skills – promoting our profession – information from one assessment tool is not a comprehensive assessment. We should act with integrity and only practice what we are skilled in and trained to do. This can and must include postgraduate training and we should value this investment in our own skills to deliver a great service to our clients. I felt ashamed of my own profession today, and here is why.
Today I chatted with a parent I was introduced to on social media. They had paid almost more money than I earn in 2 days in private practice for a 10-page report written after the parent returned a completed Sensory Profile to a therapist via the mail. Then after a 45-minute meeting where the child played on the floor while the therapist interviewed the Mum, the report and recommendations were written.
On the back of this report, the child who lives far away from the assessing therapist is now about to undertake:
Balance exercises every morning which the Mum was training to do over the internet. These include standing on one leg eyes open and eyes closed, and, hopping eyes open and eyes closed along a line.
A brushing programme; which Mum will be soon be trained to do over the internet – this needs to be done every morning and every night.
Using a sensory diet sheet and the child will follow 5 activities off this sheet each day with her TA at break-time while her friends are out on the playground.
Using a wobble cushion at lunch to facilitate eating new foods.
An after-school calming plan – spinning on a wheelie board and jumping on a trampoline for 10 mins.
The final recommendation was getting sensory therapy from a ‘Sensory OT’ if these things didn’t work. I am apparently one of the closest ‘sensory therapists’, so I got a call. The therapy has not worked. Where do I start? What is a ‘Sensory OT’? Am I one of these?
I have to be professional. So I started with educating the parent about our profession and how we practice.
Then I told her about Jean A Ayres and about Ayres’ Sensory Integration and Practitioner Education including the ICEASI. I had to dispel some myths she’d been sold that sensory diets are not related to Ayres’ Sensory Integration – exploring the history of the theory’s development, explaining how the theory should be used to inform assessment and clinical reasoning even when we can only provide advice and strategies – but that these should still be individualised following a comprehensive assessment.
The approach used and charged for is not what I recognise and not what encompasses best practice – best practice in occupational therapy, wherever we work, involves using assessment tools; some standardised and with norms or some just structured questionnaires that collect and collate our clinical observations. Then we listen and hear the client’s voice/story via their narrative and then using this to confirm our clinical observations. Then using the best possible evidence we should work alongside clients to develop goals and set a way to measure if what we then do makes a difference – improving participation in daily life.
This is not a process restricted to Ayres’ Sensory Integration, but one that should guide best practice in any area of clinical practice; judicious collection of data through assessment to inform clinical reasoning that will allow the setting on individualised, personal goals to inform intervention planning and implementation – with careful measurement of outcomes alongside reflective practice.
This is our profession – working with people in partnership, alongside them in conversation and while using assessment tools in the assessment is expected, we choose tools specific to the person, the referral reason using our clinical reasoning. This is our expertise and what makes our jobs a profession.
The Sensory Profile, like all assessments, is meant to only guide and inform clinical reasoning. Otherwise, we could just hire number crunching computer programs that use algorithms to assess plan intervention and write reports instead of OT’s.
[This blog was written a while ago, with some details changed to protect the family, but at their request and with their permission. It was written just after my father in law fell and then sadly did not recover. I was very sad anyway, but after this conversation, I was really very very sad and I waited to make sure I still felt as concerned and as sad after some time had passed.]
..but publications and research by OT’s are needed to show ASI is effective!
What more do we need to show how mainstream sensory integration theory is becoming than this recent publication in Neuroscience News. It is just a pity it says we need new therapies when we have a good one that has gold standard randomised control trials showings its effectiveness in the ASD population.
Perhaps instead what we need funding and investment for is the research to test it with other clinical populations, and across the lifepsan…this is the challenge to us all. Ad we need to tell more people about Ayres’ Sensory Integration and the growing evidence base.
Although today I was sent a copy of a link to an article entitled “First significant study on autism and homelessness”, this is not the first I have known about the increased risk of homelessness in those with Autism or ways that as a profession Occupational Therapy can offer something to help reduce this risk.
For a number of years, OT’s have been talking about the risks of loss of occupation, social connection and homelessness for their clients with Autism. We know once the structure, safety and services of childhood and school and sometimes higher education are gone, things can become tricky. And we know about Ayres’ Sensory Integration, can help minimise the impact of sensory differences on development and skills necessary for everyday life.
In 2015 a briefing for frontline staff on Autism and Homelessness suggested that 12% of people diagnosed with autism in Wales had experienced homelessness. while among rough-sleepers in Devon, 9/14 might be classified as being on the autistic spectrum.
The new study found almost identical data to the small study from Wales. The new study agrees that 12.3% of homeless people have traits of autism highly suggestive of an Autism diagnosis, in contrast to 1% in the general population.
This latest study in the peer peer-reviewed journal, Autism supports this earlier small-scale study evidence that adults with autism are over-represented among the homeless.
Now, the researchers and many organisations including the National Autistic Society are calling for more research to understand the links between autism and homelessness, so that prevention strategies can improve and support those who are at risk of becoming or are already homeless.
As an Occupational Therapist, I am perplexed and confused. Occupational Therapists working with young people with autism have for a long time repeatedly highlighted the risks of not addressing the difficulties of their paediatric clients. Ayres’ Sensory Integration therapy is about developing and learning transferrable play, school and life skills.
When this does not happen, as part of typical development, and remain unaddressed, then our young clients grow into adults with the same difficulties and challenges – this is just common sense.
“The profession of occupational therapy should now wholeheartedly embrace the opportunity to grow our profession’s reputation – addressing sensory difficulties that challenge our clients with autism and prevent them from full participation in the occupational activities they choose to engage in.” Smith @ ISIC 2018
These skills are usually learned through play, as part of typical development when a child is able to take in, make sense of and respond to the sensory events around them and within their own bodies. It is through this repeated interaction and learning via our senses that we use feedback to make memories and develop patterns of behavours.
We use then use feedback and memory to think about and anticipate (feed-forward) what to do in new and novel situations – and to make the best choice of plan and carry it out. It is this that allows us to keep doing and learning, developing patterns of behaviour and increasingly more skillful behaviors and abilities. It is our ability to accurately process and integrate sensation that allows children to eventually become independent, capable adults, participating and functioning fully in all the occupational activities that are part of our adult life.
“Sensory Integration sorts, orders and eventually puts all the sensory inputs together into whole brain function. What emerges from this process is increasingly complex behavior, the adaptive response and occupational engagement.”
We have been left a rich history and legacy by Jean A Ayres and colleagues who first developed and then tested sensory integration theory in practice. Progress in the field of neuroscience has led to further development of the theory and tools for practice; more recent developments in the field include the Fidelity Tool, Data Driven Decision Making Tool and, in development right now, the EASI (Evaluation of Ayres’ Sensory Integration), with increasingly more robust research studies with improved methodology.
More than any other profession, Occupational Therapists trained in Ayres’ Sensory Integration* have within their toolboxes the therapeutic skills to make meaningful measurable changes to their young and older client’s abilities to process and integrate sensation; learning that is truly life-changing.
Occupational Therapists trained in Ayres’ Sensory Integration* are able to address the underlying sensory challenges that research suggests underpins the difficulties commonly associated with Autism, that can impact on the development; movement, play, self-care and social interaction skills necessary to participate in occupation as we grow older.
Young people in the study group scored significantly better after therapy with Ayres’ Sensory Integration than young people in the care as usual group. Goal Attainment Scales scores and scores about self-care and socialisation skills all showed that after Ayres’ Sensory Integration Therapy* there was a significant improvement not seen in those just getting care as usual.
*Ayres’ Sensory Integration Therapy is usually a postgraduate qualification, and it is recommended that practitioners have qualifications equivalent to ICEASI Level 2. Please ask your therapist about their level of education in Ayres’ Sensory Integration.
Before I trained to be an occupational therapist, I studied neuroscience to masters by research level. It is so helpful in my work to have that underpinning knowledge of some of the things going on in the brain and how these affect behaviour. However, I don’t miss growing neurons in petri dishes and counting them.
Our kids are not great sleepers, to understate it considerably. We have had more sleep advice than anyone has any business accessing. It’s been variably effective. In the UK, there are several charities who offer sleep advice for children with special needs (Cerebra and Scope to name but 2), alongside advice from our children’s centres and child and adolescent mental health services (CAMHS). They’ve all been helpful, they’ve all prioritised the importance of a good consistent bedtime routine, on minimising distractions from sleep and on knowing your child’s sleep patterns. We have filled in more sleep diaries that you can shake a stick at (incidentally, this is the most effective way to make sure your child actually sleeps I have found! It’s amazing how well they sleep when you’re filling in a sleep diary to prove they never sleep).
I have promised myself I will stop reading sleep advice because I only get frustrated when we still don’t sleep, but here are some things we have found helpful (some nights at least!) and a little bit of the neuroscience of why.
One of our children along with many autistic people I know is taking melatonin at bedtime. The doctor tells us frequently that this is expensive, and we’d prefer to avoid medication as much as we can on general principle, so it’s worth knowing a bit about what melatonin does and how to boost it without medication.
Melatonin is a substance which the brain makes from the neurotransmitter serotonin, mostly in the pineal gland. The pineal gland is a tiny gland right in the middle of the brain and close to the visual centres of the brain. It starts making serotonin into melatonin when the light reduces, stimulating sleep onset. I don’t know whether my kids’ pineal glands are less efficient converters of serotonin to melatonin or whether their brains are less sensitive to the melatonin produced, but I just need some sleep so here are some ways we try to boost melatonin production.
Light and Screens
If melatonin is made when the light dims, it stands to reason that emphasising that light change is important, so we make sure they get lots and lots of daylight when we want them to be awake, and none when we want them to be asleep. This is not always easy in Northern England and involves a lot of getting wet and muddiness. We play outside every day we possibly can. When we can’t, we are lucky enough to have a big conservatory which we use as a playroom, and we have daylight effect lightbulbs in key rooms of the house which we use in daytime then switch to lamps in the evening. We have found that physical activity in the day can help with sleep, but if it’s all indoors such as soft play centres and swimming pools, it’s nothing like as effective as a walk outside no matter how wet the walk may be!
We have a no screens after the evening meal rule when sleep is particularly tough. Focusing visually on an (often bluish) glowing screen will inhibit melatonin production if you’re struggling to sleep, turn the technology off, it really does help.
We have blackout blinds behind blackout curtains and we close the doors of all the rooms that don’t have that every night (actually in our child who takes melatonin’s bedroom, we’ve made wooden boards which fit exactly into the window area over the Velcro blackout blind. Yes, I am serious…).
If melatonin is made from serotonin, it also stands to reason that it’s a good plan to have a lot of serotonin available to be converted. A large proportion of the antidepressants available have their effect by increasing the amount of free serotonin in the brain, this may explain some of why depression can affect sleep patterns. If you think mental health difficulties may be influencing sleep patterns, please talk to your doctor about this. It can be a vicious cycle that poor sleep exacerbates depression and depression then makes sleep more difficult, it is important to break that cycle.
There are certain foods which contain tryptophan which the brain then makes into serotonin. I know some parents who swear by these in evenings, these include cherries, nuts, seeds, tofu, cheese, red meat, chicken, turkey (you know how we all fall asleep after Christmas dinner?), fish, oats, beans, lentils, and eggs. Just be aware that strong flavours and smells can be very alerting and so be less helpful than you’d think. Also, many of these can be allergens.
It’s also good to know that serotonin and melatonin levels rise with proprioceptive activity (movement against resistance, which helps the person to understand their own body more clearly), so including (not too vigorous) movement against resistance as part of the bedtime routine can really help- moving against the water in a warm bath, followed by squeezing yourself in a soft towel would be one example, or carrying a good sized box of bedtime stories up the stairs to bed. Movement of the head can also stimulate serotonin release in the brain and help sleep, just avoid spinning and sudden changes in speed or direction as these will counteract the effects.
Doing all of this does not mean you will get a good night’s sleep (I think we got about 2 hours last night!), but it might just improve your chances.
On our courses, we teach staff from CAMHS and adult/older adult mental health services how to use Ayres’ Sensory Integration to inform care including for those who have had early trauma.
On our in-house courses, we regularly teach mixed staff teams including Mental Health Nurses and Healthcare Assistants, CPN’s, OT’s, PT’s, SLT’s and Therapy Support Staff, Complementary Therapists, Psychologists and Psychiatrists. Working with staff teams from forensic, secure, acute and longer stay units, our lecturers help teams to develop and implement sensory informed care pathways. This includes working with sensory providers to develop secure safe sensory rooms for safe self-regulation and sensory-rich movement activities suitable for secure and forensic environments, where ligature risks mean traditional swings and other equipment cannot be used.
The use of Ayres’ Sensory Integration to support health and well-being has grown across the UK and Ireland.
The research and evidence base is expanding across the globe, with more clinical audits and studies being published that report that Ayres’ Sensory Integration is
promoting participation in everyday life
increasing clients ability to engage with others, with therapy
this means that there are significant reductions in
days in secure or acute care
the use of PRN medication
the need for the use of physical support aka TMAV
We’d like to thank Tina Champagne for pointing us in the direction of this resource which fits so neatly alongside the resources and tools we teach on our courses.
Tina is a critical friend of ASI WISE and wrote several chapters in this free online resource about developmental trauma and practical ways to institute trauma-informed care.
Resources for Eliminating Control and Restraint aka Therapeutic Manage of Aggression and Violence